As the Malawi EMPOWER project continues to implement its learning and knowledge sharing agenda, the project participates in various global dissemination conferences where abstracts are submitted and presented to share some of the project’s interesting findings.

Scaling up Pre-exposure Prophylaxis (PrEP) among Adolescent Girls and Young Women (AGYW) in DREAMS clubs and service delivery adaptations: Malawi EMPOWER Experience.

Authors: Maria Mkandawire1, Fatsani Gadama 1, Nennie Lungu1, Boniface Maket1, Linda Muyumbu1, Matthew Kankhulungo1, Patrick Gwaza1, Pius Mtike1, Yona Nyondo1, Jennifer Arney2, Elled Mwenyekonde3, Ruth Kundecha ,3 Kumbukani Chawinga3 Grace Kumwenda 3 Patricia Magombo3

1 FHI 360, Malawi EMPOWER
2 FHI 360, Washington DC
3 CHAM, Malawi EMPOWER Activity
4 Pakachere , Malawi EMPOWER Activity

Oral Pre-exposure Prophylaxis is proven to be highly effective as an additional HIV Prevention method to reduce the risk of HIV acquisition (2021 Centers for Disease Control). In October 2020, the Ministry of Health, Malawi  adopted and approved the roll out of PrEP nationwide as an HIV prevention method for use particularly amongst those who are at substantial risk of contracting HIV infection ( Malawi PrEP guidelines 2020). The Malawi PrEP guidelines indicate that PrEP will be delivered in facilities and Drop-in Centers ( DICs). Barriers to accessing PrEP services in hybrid facilities included distances to certified PrEP service delivery sites, stigma associated with the use of antiretroviral drugs which are accessed in ART clinics in facilities, long queues at the facility and limited number of qualified health care workers in facilities.  The Expanding Malawi HIV/AIDS Prevention with Local Organizations Working for an Effective Epidemic (EMPOWER) project rolled out PrEP targeting AGYW by providing PrEP information at club and community level and referring to hybrid facilities for PrEP initiation. This abstract highlight service delivery adaptations for PrEP information and initiation among AGYW at the community in EMPOWER’s implementing districts of Machinga and Zomba.

In May 2021, EMPOWER rolled out PrEP at community level having trained its service providers conducting service delivery in the communities. AGYW meeting the national criteria for PrEP initiation were actively referred from mobile clinical outreach sites to certified PrEP service delivery facilities after accessing detailed information from outreach service delivery teams on use of PrEP.  AGYW were assisted at the facility to navigate the system by EMPOWER Linkage and referral coordinators and then referred back to the community for adherence support through PrEP champions and DREAMS Ambassadors.

Lesson Learned:
EMPOWER bridged the gap on long distances to PrEP service deliver sites by conducting active referrals escorting AGYW to nearest health facilities offering PrEP and through strong collaboration by Malawi EMPOWER with facility partners to provide PrEP information and PrEP initiation support at community level this has contributed to an increase in the number of AGYW accessing PrEP information from 1,114 in FY21 to 3,338 in FY22 Q2. Furthermore, the project has seen an increase in the number of AGWY initiated on PrEP from 165 in FY21 to 696 in FY22.

Successful PrEP implementation at scale   for AGYW requires adaptations in service delivery as most AGYW prefer to access PrEP in non-clinincal settings. A combination of  facility and community-based settings are required to address issues of  stigma and discrimination  and  distances to certified PrEP service delivery sites which are barriers to PrEP service uptake.

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Sexually Transmitted Infections Incidence Among Adolescent Girls and Young Women (AGYW) age groups: Malawi EMPOWER Experience

Authors: Yona Nyondo,1 Nennie Lungu,1 Matthew Kankhulungo, 1 Maria Mkandawire,1 Patrick Gwaza,1 Linda Muyumbu, 1 Boniface Maket,1 Jennifer Arney2, Patricia Magombo,3 Ruth Kundecha,3 Tadala Simika,4 Kumbukani Chawinga4

 1 FHI 360, Malawi EMPOWER
2 FHI 360, Washington DC
4 Pakachere, Malawi EMPOWER

The Expanding Malawi HIV/AIDS Prevention with Local Organizations Working for an Effective Epidemic (EMPOWER) supports the Government of Malawi (GoM)’s commitment to epidemic control by stopping HIV transmission and preventing new HIV infections to adolescent girls. Sexually transmitted infections (STIs) are among the top disease categories for which AGYW seek healthcare services. According to the World Health Organization (WHO), (2005), the highest rates of sexually transmitted infections (STIs) are among the 15-24 age group globally. Furthermore, a study (Torrone EA, et al, 2018), across three primary African regions revealed that all STIs, except Herpes Simplex Virus 2, were more prevalent among AGYW, 15–24 years. These results are in correlation with the EMPOWER FY21 data reported in the shared database. This paper seeks to highlight STI incidences among AGYW age-bands.

The secondary analysis utilized collected longitudinal data from 385 STI positive AGYW aged 10-24 years, collected across the 52 sites of Zomba and Machinga districts, between Q1 and Q4 of FY21. Service delivery teams used the STI risk assessment tool to assess risk during service provision. EMPOWER uses the Syndromic Management Approach (SMA) to manage STIs. Hence for all AGYW with a positive STI screen, service delivery teams identified syndrome, diagnosed, and treated or referred accordingly. Quantitative data were analyzed using Microsoft Excel.

Overall, EMPOWER offered STI information to 28,345 AGYW in FY21, of which 385 AGYW were diagnosed for STI, 71% were treated at outreach clinics and 29% were actively referred to health facilities. Specific to incidence among subgroups in cases diagnosed STI positive, the 15-24 years accounted for an average of 84% across all quarters (Q1: 93%, Q2: 81%, Q3: 83%, Q4: 89%) of FY21.

Our finding that the prevalence of both STI was higher among AGYW aged 15-24 years is consistent with WHO (2018), which reports that although STIs affect all age-groups, AGYW aged 15–24 years are particularly more vulnerable. This is not surprising given that these young women were more likely to engage in sex with multiple partners, and to be less likely to use condoms consistently with partners. These findings call for need for target-specific risk-reduction interventions stratified by age group.

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Community based strategies to increase access for HIV self-testing among Adolescent Girls and Young Women (AGYW): Malawi EMPOWER Experience

Authors: Nennie Lungu,1 Matthew Kankhulungo, 1 Linda Muyumbu, 1 Boniface Maket,1 Maria Mkandawire,1 Yona Nyondo,1 Leo Magombo1, Jennifer Arney2

 1 FHI 360, Malawi EMPOWER
2 FHI 360, Washington DC

Adolescent girls and young women (AGYW) make up a disproportionate share of persons living with HIV in sub-Saharan Africa. There is therefore a critical need for implementation research on strategies for increasing access to HIV testing, prevention, and treatment for this priority population. Research by the USAID-funded program EMPOWER (Expanding Malawi HIV/AIDS Prevention with local organizations Working for an Effective Epidemic Response whose goal is to support the Government of Malawi (GOM)’s commitment to epidemic control by stopping HIV transmission and preventing new HIV infections, particularly among AGYW has demonstrated that offering HIV testing options including self-testing through community outreach clinics is a promising strategy that may overcome many of the barriers to accessing HTS among AGYW. This abstract describes how EMPOWER contributed to reaching more AGYW with HIV self-test kits.

In January 2021, EMPOWER initiated an extended community outreach model of service delivery to AGYW in DREAMS clubs which takes HIV testing services closer to communities where the AGYW reside. The outreach clinics were offered at safe spaces and flexible times convenient to the girls. Through the outreach clinics, risk reduction sessions were offered to AGYW through targeted one-on-one and small group sessions to increase demand for HIV testing and prevention services. Risk assessment tool was administered before offering self-test kits to AGYW. Directly assisted self-testing approach was promoted by trained service delivery teams to ensure that AGYW test and interpret their HIV test result. The provider helped to ensure accuracy of results and for easy follow-up on the self-test outcomes.

Using community outreach clinics to offer HIV testing services to AGYW contributed to an increase in the number of HIV self-test kits distributed to AGYW from 1,870 in FY21 Q1 to 10,460. The achievement represents 99% of the HIV self-testing distribution target of 10,492. Of the test-kits distributed, 9,937 were distributed through the directly assisted model representing 95% with the reminder of 5% (n=523) being self-test kits distributed through unassisted model. The HIV self-test kits were distributed to 10,253, AGYW. Of those who accessed the kits 30 were screened reactive and were all confirmed positive through conventional testing. All confirmed positives were initiated on treatment and thus having a 100% linkage rate to ART treatment.

Expanding community-based HIV self-testing with facilitated linkage has the potential to reduce coverage gaps and increase the proportion of AGYW linked to HIV treatment and prevention

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national agyw symposium poster

Use of Tracker to enhance Oral pre-exposure prophylaxis adherence among Adolescent Girls and Young Women in DREAMS Clubs - Zomba EMPOWER Pakachere experience

Authors: Tadala Simika1, Andrew Chumachienda1, Kumbukani Chawinga1, Allan Kalande1, Oramah Bokosi1, Bright Mkandawire1, Efred Mfitilodze1, Ephraim Kwachera, Maria Mkandawire2, Nennie Lungu2, Patrick Gwaza2, Pius Mtike2, Fatsani Gadama2, Mathew Kakhulungo2, Yona Nyondo2   1 Pakachere, Malawi EMPOWER 2 FHI360, Malawi EMPOWER
Introduction Adolescent girls and young women (AGYW, aged 15-24 years) bear a disproportionate burden of HIV infection. Fortunately, oral pre-exposure prophylaxis (PREP) is a self-initiated option to reduce AGYW-HIV risk as such AGYW who wish to use oral PREP understand their risk and want to protect themselves from HIV acquisition. Zomba EMPOWER-Pakachere creates demand through provision of PREP information, ensures active referral of AGYW at risk of acquiring HIV. This abstract highlights the strategies which Zomba EMPOWER-Pakachere use to enhance oral PREP among AGYW in DREAMS clubs who are at risk of HIV infections. Methodology Zomba EMPOWER-Pakachere service providers reach out to Adolescent Girls and Young Women (AGYW) in DREAMS clubs in six facility catchment areas of Likangala, Mayaka, Matiya, Magomero, Thondwe and Namikango. To create demand and enhance Prep uptake among AGYW, EMPOWER Pakachere service providers provides PREP information before service provision and those that are eligible for PREP are actively referred to nearest health facility where PREP services are offered. In addition, Zomba EMPOWER-Pakachere also use PrEP tracker which acts as a reminder on the next date of appointment as well as outcomes for PREP AGYWs.  Good collaboration between EMPOWER and treatment partners (EGPAF and MOH)  as well as use of cadres (YCBDAs, PREP champions, DREAMS ambassadors and Ana Patsogolo DREAMS facilitators) who assist in provision of PREP information, mobilization, and active referral of AGYW who eligible and  following up all those who are due for a refill according to the tracker  Furthermore, Zomba EMPOWER-Pakachere provides transport to referred PREP AGYW from hard to reach to health facility to access PREP services. To understand the impact of these strategies, Zomba EMPOWER-Pakachere analyzed data from April 2021 to June,2022. Results From the period April 2021 to June,2022, the total number of AGYW PrEP continuation increased from 47 in FY2021 Q3 to 112 in FY2022 Q3 representing 297% achievement of quarterly target of 38. The increase from FY2021 Q3 to FY2022 Q3 demonstrated improvement on PrEP continuity with the use of PrEP tracker thereby reducing risk of HIV infections among AGYW in DREAMS Clubs. Conclusion Use of PrEP tracker for tracking AGYW on PrEP is a key strategy to enhance oral pre-exposure prophylaxis among adolescent girls and young women in DREAMS clubs. Recommendations Community based PrEP services can enhance uptake of PrEP among AGYW as they will be accessing PrEP services right at the community rather than walking long distances to access PrEP at the facility. Tracking of PrEP-AGYW can improve adherence as the AGYW cannot miss date of appointment thereby reducing risk to HIV infections among adolescent girls and young women in DREAMS clubs. Collaboration with community partners, clinical partners and community cadres will also enhance PrEP uptake among AGYW.
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national agyw symposium poster

Barriers to Pre-Exposure Prophylaxis (PrEP) among adolescent girls and young women (AGYW) in Machinga: Malawi EMPOWER experience

Authors: John Kumwenda1, Ruth Kundecha1, Lawrence Mpende1, Nennie Lungu2, Boniface Maket2 Maria Mkandawire2  

2 FHI360, Malawi EMPOWER

Pre-Exposure Prophylaxis (PrEP), a drug taken to prevent HIV, is a safe and effective prevention option for all populations at substantial risk of HIV acquisition when taken as prescribed. Malawi EMPOWER offers PrEP to adolescent girls and young women (AGYW) in DREAMS clubs in Zomba and Machinga as part of its comprehensive package of services. This abstract aims to assess barriers to PrEP uptake by adolescent girls and young women(AGYW) in Machinga.

The study design was cross-sectional and employed qualitative approaches, namely focus group discussions and key informant interviews. A simple random sampling technique was deployed to select facilities from which data was collected. In total, three health facilities were selected, and three focus group discussions were conducted involving AGYW 15 to 24 years eligible for PrEP. In total 30 AGYW were interviewed. A total of six key informants being Dreams’ club facilitators were interviewed. Thematic analysis was used.

Study findings
The study findings showed that, the general understanding of PrEP was that ‘PrEP is offered to individuals, particularly girls who are HIV negative to prevent them from contracting HIV’. Furthermore, on barriers to accessing PrEP under social/community challenges, results revealed that AGYWs are usually mocked by their friends, other health users, and their families by saying ‘they are taking ARVs though not sick and even calling them names in vernacular’ insinuating that ‘‘they indulge in high risk sex hence the need  to  take ARVs.’ On economic and strategic challenges, the results showed that girls are affected by long distances and long travel hours to PrEP service delivery sites including long queues in facilities. Regarding health challenges, AGYW on PrEP experience nausea and stomach pains after taking PrEP, especially in the first days of taking the drug.

Long distances to PrEP delivery sites and social/community myths are the major drawbacks for the PrEP intake by Adolescent Girls and Young Women in the Machinga district. This would also affect the sustainability of the PrEP initiative.

Recommendations for PrEP Initiative
The study recommended conducting community dialogues and sensitization meetings with parents and or guardians of the AGYW to demystify the negative perceptions upheld by the community.  In addition, taking PrEP closer to AGYWs by utilizing existing forums where girls meet such as clubs to curb the long distance and queues barrier.

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dhis2 2022 poster

Use of data from DHIS2 to improve project performance for Adolescent Girls and Young Women (AGYW) programming: Malawi EMPOWER Experience

Authors: Nennie Lungu,1 Linda Muyumbu, 1 Matthew Kankhulungo 1 Boniface Maket,1 Maria Mkandawire,1 Yona Nyondo,1 1 FHI360, Malawi EMPOWER
Introduction The goal of the Expanding Malawi HIV/AIDS Prevention with Local Organizations Working for an Effective Epidemic (EMPOWER) project is to support Government of Malawi (GoM)’s commitment to epidemic control among AGYW of 10–24 years through provision of sexual and reproductive health (SRH) and HIV services. Despite the project’s collection and access to high quality SRH/HIV data, platforms to periodically analyze and use the data to improve performance were minimal. This paper describes how the project used DHIS2 tracker data during data review meetings to improve performance of the AGWY programming in the EMPOWER project. Methodology In March 2021, EMPOWER initiated Total Quality Leadership and Accountability (TQLA) a FHI 360 model of reviewing program performance daily and making course corrections through situation room meetings. The model requires setting daily targets and, use of granular level data to monitor performance to enable program improvement. We used DHIS 2 tracker version 2.33.8 to capture, analyze and visualize data individual data on three key SRH/HIV indicators during these meetings to identify challenges in AGYW service provision and prioritize local solutions to improve project performance. We integrated the DHIS2 tracker with real-time interactive Power Business Intelligence (BI) dashboards at community, district and project levels to track project indicators with required disaggregation. Results Using DHIS 2 tracker to systematically analyze, visualize and review granular level data during situation room meetings led to targeted program adjustments and contributed to an increase in the number of AGYW reached with standardized evidence based SRH/HIV from 13,608 in FY21 Q1 to 56,142 AGYW in FY21 Q4. Of those reached, 13,662 (representing 91% of the annual HIV testing (HTS) target of 15,008) accessed HIV testing services through conventional testing and 46 were identified as new positives. All 46 were initiated on treatment representing 100% linkage rate. 10,460 HIV self-test kits were distributed to 10,253, AGYW which represents 99% of the annual HTS self-testing target of 10,492. Of those who accessed the kits 30 were screened reactive and were confirmed positive and all were initiated on treatment. Conclusion The use of DHIS2 tracker for systematic, periodic granular site level data analysis through structured platforms such as weekly situation room meetings optimize use of data to improve project performance on key indicators such as overall reach with SRH/HIV services, linkage to care for community interventions targeting AGYW. The process helps identify local solutions and strengthens capacity of implementers to use data.
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Malawi EMPOWER’s use of demand-creation strategies for sexual and reproductive health services for adolescent girls and young women during COVID-19 in Zomba and Machinga Districts

Authors: Patrick Gwaza1, Yona Nyondo1, Nennie Lungu1, Boniface Maket1, Maria Mkandawire1, Linda Muyumbu1, Matthew Kankhulungo1, Patrick Gwaza1, Pius Mtike1, Fatsani Gadama1, Leo Magombo1, Jennifer Arney2, Elled Mwenyekonde3, Patricia Magombo3
1 FHI360, Malawi EMPOWER Activity 2 FHI360, Washington DC 3 CHAM, Malawi EMPOWER Activity Background Adolescent girls and young women (AGYW) in Malawi bear a disproportionate burden of HIV compared to male peers; HIV prevalence is 2.3 times higher among young women ages 15–24 compared to young men the same age, according to the 2018 Malawi Population-Based HIV Impact Assessment. High access to and utilization of sexual and reproductive health (SRH) services among AGYW ages 10–24 requires increased use of demand-creation strategies in communities. This abstract highlights the USAID-funded Malawi EMPOWER Activity’s use of digital platforms in demand-creation strategies to increase SRH service uptake among AGYW in Zomba and Machinga Districts during the COVID-19 pandemic. Description: Social and behavior change communication interventions were adapted to fit Malawi’s COVID-19 restrictions, which suspended direct community mobilization. To eliminate barriers to service access by increasing awareness of the services being provided in targeted districts, demand-creation messages on the benefits of services and service delivery schedules were shared with AGYW, community mobilizers, and health care workers through social media (Facebook, WhatsApp groups) and other digital platforms such as radio. Lesson Learned: Malawi EMPOWER began implementation in March 2020, just when the Malawi government established restrictive measures against COVID-19. These restrictions suspended demand-creation activities such as dialogue sessions with AGYW, Go! Girls Clubs sessions, community special events, advocacy meetings, and campaigns. From March to April, EMPOWER experienced a 40% drop in AGYW accessing SRH, HIV, and gender-based violence (GBV) services due to the ban on these activities. Following implementation of adapted strategies from the end of April to August 2020, 28,971 AGYW were reached with SRH services (family planning methods, counseling), including HIV testing services, representing a 73% achievement of the annual target of 39,643. Of these, 64% (n=17,090) were ages 10–14, 27% (n=7,051) were ages 15–19, and 9% (n=2,421) were ages 20–24. Conclusions: Although COVID-19 has presented barriers to full implementation of mobilization activities affecting the uptake of SRH/HIV/GBV services among AGYW, an adapted package of demand-creation strategies implemented through social media and other digital platforms was successful in reaching this population with messages and services.
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Optimizing digital data collection using DHIS2 in Adolescent Girls and Young Women (AGYW) programming: Malawi EMPOWER Experience

Authors: Nennie Lungu,1 Matthew Kankhulungo, 1 Linda Muyumbu, 1 Boniface Maket,1 Maria Mkandawire,1 Yona Nyondo,1 Leo Magombo1 1FHI 360, Malawi EMPOWER
Introduction The Expanding Malawi HIV/AIDS Prevention with Local Organizations Working for an Effective Epidemic (EMPOWER) project is a large-scale multifaceted program that provides sexual and reproductive health (SRH) and HIV services to more than 40,000 adolescent girls at 40 sites across Malawi. The project team used DHIS2 to ensure the availability of high-quality data in a timely manner to guide program design and inform mid-course corrections. This abstract describes how the DHIS2 tracker was implemented across diverse sites with limited internet connection to collect real-time data, reducing data transmission time, lowering data entry costs, and providing real time data for analysis and programming. Methodology In June 2020, EMPOWER developed a database using DHIS2 tracker version 2.33.8 to capture longitudinal data for SRH/HIV services provided to AGYW during monthly community outreach. The DHIS2 tracker collects individual data and runs on both the computer and android devices for offline data capture. We conducted a one-week training for data entry clerks on data capture, cleaning and analytics using the DHIS2 tracker using tablets. Currently the tracker is deployed to capture individual level data at 40 community outreach sites for more than 40,000 AGYW monthly. Results Using the DHIS2 tracker, we collected data at multiple outreach sites. DHIS2 tracker allows instant merging of longitudinal records unlike other routine statistical software packages where the process took more than a week to complete. Skip patterns and other internal data quality checks within the tracker help improve completeness and accuracy of data. EMPOWER can track HIV services among AGYW over-time to determine impact of its interventions. Using the DHIS2 tracker, EMPOWER has saved over $10,000 by purchasing tablets instead of computers as were previously needed. The tracker also enabled the project to efficiently develop analytical dashboards to track performance and thus aid in improving programming. Conclusions Use of DHIS2 tracker and app for longitudinal data collection for community outreach programs with large number of beneficiaries ensures data is collected and captured at different delivery points, times and merged instantly to inform programming, through real-time analytics within the platform. It also is cost effective and scalable.
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Use of male champions to improve male involvement in HIV testing: The experience of the Malawi EMPOWER Activity

Authors: Nennie Lungu,1 Boniface Maket,1 Maria Mkandawire,1 Linda Muyumbu,1 Yona Nyondo,1 Matthew Kankhulungo,1 Patrick Gwaza,1 Pius Mtike,1 Fatsani Gadama,1 Leo Magombo,1 Jennifer Arney,2 Kumbukani Chawinga,3 Allan Kalande,3 Oramah Bokosi,3 Efred Mfitilodze,3 Tadala Simika,3 Andrew Chumachienda,3 Bob Phiri,3 Geofrey Makina3
1FHI 360, Expanding Malawi HIV and AIDs Prevention with local Organization working for an Effective Epidemic Response (EMPOWER) 2FHI 360, Washington, DC, USA 3Pakachere, Malawi EMPOWER Activity, Zomba, Malawi Background   Men living with HIV in Malawi have low rates of health-seeking behaviors, tend to present at clinics with advanced HIV, and have low viral load suppression rates. Research by the USAID-funded program EMPOWER (Expanding Malawi HIV/AIDS Prevention with local organizations Working for an Effective Epidemic Response) on men’s barriers to HIV services and beneficiary engagement has demonstrated men’s preference for male providers and for flexible and confidential service delivery models. To reach men, EMPOWER provides education on HIV prevention behaviors, creates demand for HIV testing services (HTS), ensures that men know their HIV status, and encourages linkage to treatment and care for HIV-positive men. Here, we describe how EMPOWER contributed to reaching more men with these services. Methods EMPOWER reaches priority populations such as estate workers, fisherfolk, and male partners of adolescent girls and young women using targeted one-on-one and small group sessions on risk reduction. To encourage participation, EMPOWER uses trained male champions who are members of these populations to provide men with services. In addition, EMPOWER’s community-based testing approach brings HTS closer to men by offering services at times and locations that are convenient for them. To understand the effectiveness of this approach, EMPOWER analyzed program data for HTS from April to September 2020. Results: During the period under review, the number of men tested increased from 41 in Q3 FY20 (April–June 2020) to 1,034 in Q4 FY20 (July–September 2020) (Figure 1). In Q4, men accounted for 47 percent of the quarterly target. In addition, the number of men newly tested positive for HIV increased from 22 in Q3 FY20 to 84 in Q4 FY20. Of the males tested in Q4 through the male champion strategy, 651 were new testers and these accounted for 63 percent of those tested. On the other hand, the reminder 383 were repeat testers (last negatives). The positivity rate among the new testers was at 9.3 percent as compared to repeat testers which was at 6 percent. Hence use of male champions increased the likelihood of accessing testing services by hard-to-reach segments of the population who might never have had a chance to be tested at the health facility. Conclusions Use of male champions and bringing HTS to men is a promising strategy for increasing male participation in HIV prevention and testing services. Male champions also have the potential to significantly increase promote testing among first time testers who cannot access testing at health facilities.
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